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The main aims of the oncologic surgeon should be an early tumor diagnosis, complete surgical resection, and a careful post-treatment follow-up to ensure a prompt diagnosis of recurrence. Radiologic and endoscopic methods have been traditionally used for these purposes, but their accuracy might sometimes be suboptimal. Technological improvements could help the clinician during the diagnostic and therapeutic management of tumors. Narrow band imaging (NBI) belongs to optical image techniques, and uses light characteristics to enhance tissue vascularization. Because neoangiogenesis is a fundamental step during carcinogenesis, NBI could be useful in the diagnostic and therapeutic workup of tumors. Since its introduction in 2001, NBI use has rapidly spread in different oncologic specialties with clear advantages. There is an active interest in this topic as demonstrated by the thriving literature. It is unavoidable for clinicians to gain in-depth knowledge about the application of NBI to their specific field, losing the overall view on the topic. However, by looking at other fields of application, clinicians could find ideas to improve NBI use in their own specialty. The aim of this review is to summarize the existing literature on NBI use in oncology, with the aim of providing the state of the art: we present an overview on NBI fields of application, results, and possible future improvements in the different specialties.

Soft tissue sarcomas are a heterogenous group of malignant tumors that represent approximately 1% of adult malignancies. Although these tumors occur throughout the body, the majority involved the lower extremity. Management may involve amputation but more commonly often includes wide local resection by an oncologic surgeon and involvement of a plastic surgeon for reconstruction of larger and more complex defects. Postoperative wound complications are challenging for the surgeon and patient but also impact management of adjuvant chemotherapy and radiation therapy. To explore risk factors for wound complications, we reviewed our single-institution experience of lower-extremity soft tissue sarcomas from April 2009 to September 2016. We identified 127 patients for retrospective review and analysis. The proportion of patients with wound complications in the cohort was 43.3%. Most notably, compared with patients without wound complications, patients with wound complications had a higher proportion of immediate reconstruction (34.5% vs 15.3%; P = 0.05) and a marginally higher proportion who received neoadjuvant radiation (30.9% vs 16.7%; P = 0.06).

Background and objectives Cemented hip arthroplasty is considered the standard of care for treating both osteoporotic femoral neck fractures and pathologic disease of the proximal femur due to the ability to achieve strong fixation in poor quality bone. There is minimal literature evaluating uncemented arthroplasty for pathologic disease of the proximal femur. This objective of this study is to compare outcomes of patients undergoing cemented and uncemented arthroplasty of the proximal femur for an oncologic indication. Methods Patients who underwent hip arthroplasty procedures in one health system for an oncologic indication were identified. Demographics, cancer history, operative history, and complications were collected retrospectively. Harris Hip Scores (HHS) and Musculoskeletal Tumor Society Scores (MSTS) were prospectively collected via telephone. Results 41 patients met criteria for review. 18 underwent cemented and 23 underwent uncemented arthroplasty. There were no significant differences in age, demographics, complications, 30-day mortality, intraoperative blood loss, transfusion requirements, average HHS, or average MSTS. Conclusion No significant differences were found for patients undergoing hip arthroplasty for an oncologic indication regardless of whether or not the femoral component was cemented. Our results suggest that cemented and uncemented techniques are both safe and effective methods to be used at the oncologic surgeon's discretion.

Background Orbital reconstruction following oncologic midface resection is uniquely challenging, and makes critical contributions to patient aesthetics, function, and identity. Approach is largely dependent on surgeon and patient preferences, and there exists no consensus on defect characterization. Objective The goal of the study is to provide a mental framework for the reconstructive oncologic surgeon to use as a foundation during his or her approach to the orbit. Design The design of the study is based on the review of current literature and expert opinion. Conclusions Critical versus optimal objectives must be set in orbital reconstruction, and a systematic approach should be followed. We approach orbital reconstruction by first deciding whether globe-sparing surgery is possible, or if orbital exenteration will be necessary. We then set critical and optimal objectives for our chosen pathway. Critical goals in globe-sparing reconstruction include maintaining orbital volume and preserving visual function, and an optimal goal includes preservation of the nasolacrimal system. Critical goals in orbital exenteration include obliterating the defect, sealing the skull base and nasal cavities, and allowing eye protection to be worn over the contralateral eye postoperatively. Optimal goals in exenteration include preparation for prosthetics, volume and bony replacement, eyelid-sparing technique, and consideration of postoperative radiation.

Implant-based breast reconstruction has evolved through advances in mastectomy and reconstruction techniques to offer excellent outcomes with both prepectoral and subpectoral implant placement. Proper patient selection and surgical technique are key for optimizing outcomes and minimizing complications regardless of implant location. Therefore, familiarity with the benefits and limitations of each technique is vital. Several patient characteristics, such as history of significant comorbidities, radiation or active smoking, portend higher risk of complications with prepectoral reconstruction, in which case subpectoral implant placement may be a safer option. Oncologic consideration such as location and size of tumors also play an important role in determining the appropriate technique. The most critical factor in the success of prepectoral reconstruction is the quality of mastectomy flaps. Thorough intraoperative evaluation of mastectomy flap perfusion and viability will determine whether immediate prepectoral reconstruction is possible or other alternatives such as subpectoral or delayed prepectoral techniques should be considered. Discussing these factors with patients preemptively as well as developing a coordinated plan with the patient and oncologic surgeon will maximize success in both subpectoral and prepectoral implant-based reconstruction.

Transoral robotic surgery (TORS) now offers extended reach and capability to the head and neck oncologic surgeon, but in doing so, provides a reconstructive dilemma. The objective of this manuscript is to discuss the most recent advances and options available after resection with TORS. The latest research provides a common framework for surgeons to classify the type of oropharyngeal defect. A variety of reconstructive options described include secondary intent, modifications to existing local and regional flaps, and advances utilizing robotic assistance in free flap reconstruction. There exists a multitude of reconstructive options with appropriate considerations for a stepwise approach based on patient-specific factors, surgeon capability, and the extent of the oropharyngeal defect. Just as robotic resection extends the capability in extirpation, it is now being used to refine free flap inset in the appropriate case.

With the spread of positron emission tomography/magnetic resonance (PET/MR), the question of comparability of studies becomes important. We aim to determine whether PET/MR and PET/computed tomography (PET/CT) are comparable for the case of cervical cancer. Fifteen cervical cancer patients identified by either a radiation oncologist or an oncologic surgeon had both PET/MR and PET/CT performed for initial staging within 3 weeks. We then compared the results both quantitatively (measuring standardized uptake values [SUVs] on visible lesions) as well as qualitatively (having radiologists and nuclear medicine physicians interprets the results). While interpretations between PET/MR and PET/CT varied in many cases, SUVs of primary lesions were similar to within 25% in all but one case, and correlation coefficient was 0.92. Maximum SUV ranged between 4.9 and 25.2 for PET-MR and between 5.8 and 30.4 for PET-CT for primary tumors and between 1.5 and 18.8 for PET-MR and between 1.8 and 20.8 for PET-CT for nodes. However, clinical reads often varied significantly between PET/MR and PET/CT. This suggests that SUV is similar on PET/MR and PET/CT although the differing anatomic modalities available for correlation may make the difference in terms of qualitative interpretation.

Deep lobe parotidectomy (DLP) is a critical procedure to master for any head and neck oncologic surgeon. This procedure is indicated for any deep lobe malignancy, a superficial lobe malignancy with extension into the deep lobe, refractory inflammatory conditions, and the presence of metastatic disease within a superficial or periparotid lymph node. This article describes the relevant anatomy and steps required to perform a deep lobe parotidectomy with and without facial nerve sacrifice. In addition, the history of the procedure, patient work up, indications, and possible complications are discussed.

Clinical face transplantation, only 10 years old, has evolved into a safe and preferred reconstructive option for the most severe facial defects, in which traditional reconstructive methods have yielded poor outcomes. The ability to simultaneously restore facial function and aesthetics has shown to improve patient's quality of life. Its applicability to post-oncologic resection, however, remains guarded given the current international experience with respect to long term outcomes. J. Surg. Oncol. 2016;113:971-975. © 2016 Wiley Periodicals, Inc.

The nevoid basal cell carcinoma syndrome (NBCCS) is a genetic disorder that affects the PTCH gene, which is highly associated with tumor suppression. It presents a case of NBCCS diagnosed in a 49-year-old Caucasian male. His medical history has shown a great number of surgical procedures for the removal of lesions that are common to the syndrome. One of the lesions was removed from the mandible and sent for biopsy. The patient was diagnosed by means of a jaw biopsy conducted by a buccomaxillofacial surgeon, and histopathologic sections showed a diagnosis of odontogenic keratocyst (OKC) and squamous cell carcinoma (SCC). Also, in the same section, some calcified materials were found that refer to psammoma bodies. The patient is still under care with an oncologic surgeon for future surgeries given the nature of the disorder. This case illustrates the importance of a multidisciplinary team in the diagnosis and treatment of patients with NBCCS.

Purpose of review Midfacial defects resulting from head and neck oncological resections can be addressed by microvascular reconstructive techniques using autologous tissue. In specific indications, however, prosthetic rehabilitation can give a superior aesthetic outcome, combined with a less intensive surgical strain on the patient. In other situations, the combination of both approaches can restore much extended defects satisfactorily. This review lists the indications, technical prerequisites for success, and outcome of midface prosthetic rehabilitation. Recent findings With increasing numbers of patients treated, the optimal treatment protocol has become clear, and is now validated by long-term results in accumulating patient numbers. Modern three-dimensional planning techniques and three-dimensional printing of drill-guides, custom-made implants, abutments and epitheses further increase the predictability of success and the aesthetic outcome. Summary Midface prosthetic rehabilitation nowadays has a definite place in the armamentarium of the head and neck oncologic surgeon and is invaluable in restoring quality of life and social functioning of patients with extensive midfacial defects following oncological resections.

The cavity left by the removal of tumors represents a challenge for the orthopedic oncologic surgeon. This article takes a critical look at the use of a synthetic bone graft to fill the residual space. A combination of hydroxyapatite, tricalcium phosphate, and bovine collagen was used for intramedullary tumors. Thirty patients were followed for an average of 23 months. The majority (93%) returned to full activity with only 6 (20%) complications. Study results showed collagen and biphasic calcium phosphate ceramic bone graft makes an effective substrate for filling intramedullary cavities remaining after tumor excision.

Fifty years after the development of pelvic exenteration, the operation remains a gold standard in the surgical management of advanced pelvic malignancy. The operation has evolved through several predictable phases including technical improvements, lowered morbidity and mortality, and improved patient selection. Despite progress in supportive peri-operative care, pelvic exenteration is a major undertaking that should be performed in centers with proven interest and expertise in the field. We trace the early developments of the operation, the period of maturation, and the current place of this procedure in the armamentarium of the oncologic surgeon. Semin. Surg. Oncol. 17:147–151, 1999.© 1999 Wiley-Liss, Inc.

Summary Surgery for malignant tumors of the maxillofacial region has benefited significantly from advances in imaging technology and instrumentation and in maturation of craniofacial and orthognathic reconstructive surgical techniques during the past two decades. These developments allow the maxillofacial oncologic surgeon to precisely visualize the anatomic involvement of the malignant process in order to better determine exactly which surgical ablative procedure is of greatest benefit to the patient. Reconstructive surgical options are available that are not solely dependent on local tissues or delayed staged tissue transfers, enabling the surgeon to obtain satisfactory resection margins at the ablative surgical site and at the same time offering the patient the possibility of immediate restoration of anatomic form and an expeditious return of function depending on the specific malignant tumor treated. This review deals with some of the most common approaches to surgically treating malignancies of the maxilla and mandible, in addition to providing a brief review of malignant tumor-specific behavior and surgical recommendations as they relate to those malignancies of the jaws that have traditionally been treated through surgery. It is hoped that those colleagues dealing in maxillofacial surgical oncology will continue to report their findings so that these unfortunate patients can continue to benefit from evolving advances in this exciting field.

Summary The head and neck oncologic surgeon must continue to keep abreast of advances in surgical oncology, as well as radiation oncology, medical oncology, and basic sciences. It is encouraging to see for the first time a reduction in the mortality rate from oral cavity cancer. These advances must be expanded to further reduce mortality and morbidity rates and to raise the quality of life for our patients with head and neck squamous cell carcinoma.

Background Head and neck oncologic surgery is a time-consuming specialty that requires extensive resources and manpower. Case mix index (CMI) is used in evaluating the complexity and economic impact of surgeons. Head and neck oncologic surgeons generate significant revenue for hospitals, yet compensation is relatively low. Methods Retrospective review of a tertiary hospital's case mix data for 605 otolaryngology admissions from 2009 to 2011 was performed. CMI comparison for head and neck oncologic surgeons versus general otolaryngology was performed. Results In an otolaryngology department of 9 surgeons; there was a significant difference (p 1) favoring head and neck oncologic surgeons. Conclusion Head and neck oncologic surgeons increase the CMI for hospitals and ultimately influence the hospital's reimbursement. There is a need for increased collaboration between hospitals and departments in fostering and furthering their head and neck surgical oncology programs by taking CMI into consideration. © 2013 Wiley Periodicals, Inc. Head Neck, 36: 1420–1424, 2014

Optical image-guided cancer surgery is a promising technique to adequately determine tumor margins by tumor-specific targeting, potentially resulting in complete resection of tumor tissue with improved survival. However, identification of the photons coming from the fluorescent contrast agent is complicated by autofluorescence, optical tissue properties, and accurate fluorescent targeting agents and imaging systems. All these factors have an important influence on the image that is presented to the surgeon. Considering the clinical consequences at stake, it is a prerequisite to answer the questions that are essential for the surgeon. What is optical image-guided surgery and how can it improve patient care? What should the oncologic surgeon know about the fundamental principles of optical imaging to understand which conclusions can be drawn from the images? And how do the limitations influence clinical decision making? This article discusses these questions and provides a clear overview of the basic principles and practical applications. Although there are limitations to the intrinsic capacity of the technique, when practical and technical surgical possibilities are considered, optical imaging can be a very powerful intraoperative tool in guiding the future oncologic surgeon toward radical resection and optimal clinical results. Clin Cancer Res; 19(14); 3745–54. ©2013 AACR.

Knowledge about the radiation medicine as a whole has gained importance in the recent past due to better understanding of not only the physical and biological principles but also advancements in the technology and better understanding of oncological principles. This review will try to address some of these aspects that are considered relevant to a surgeon dealing with oncology cases. With recent advancements we are able to achieve a better therapeutic ratio, that is more dose to the tumour and lesser dose to the normal tissues. This review will help the surgeon in understanding the basics and also be aware of the recent advances in radiotherapy.

Although breast reconstruction with deep inferior epigastric perforator (DIEP) flap is a well-described technique, few publications have specifically reported the technical aspects and the outcome following skin-sparing mastectomy (SSM). The aim of this study is to analyse the feasibility of its immediate application and to describe the operative planning, outcome and complications after SSM. 27 patients underwent 30 DIEP flap breast reconstructions with all immediate and 3 bilateral. Mean time of follow-up was 29 months. Breast skin, DIEP Flap and donor-site complications were evaluated. Information on patient satisfaction was collected. 70% had tumors measuring 2 cm or less (T1) and 74% were stage 0 and I according to American Joint Committee on Cancer. Breast skin complications occurred in 7.4%, all represented by small areas of skin necrosis. Partial losses were observed in two (7.4%) patients (less than 15% of total area) and total DIEP loss in 1 (3.7%). Donor-site complications represented by bulging occurred in only one patient (3.7%). The majority of patients were either very satisfied or satisfied. One local recurrence was observed. All complications except 2 were treated by a conservative approach. The DIEP flap is a reliable technique for SSM reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon and careful intraoperative and postoperative management. The main advantage is that patients can safely undergo dual procedures with the added aesthetic benefits in breast and abdominal donor site.

Diagnostic image-guided needle biopsy plays a vital role in the work-up and treatment of patients with extremity bone tumors. The radiologist and the orthopedic oncologic surgeon should take a team approach to this procedure, especially when the bone lesion might be a primary sarcoma for which limb-sparing surgery (LSS) would be considered. A set of anatomically based guidelines were developed that can be used by the radiologist, in combination with case-by-case consultation with the surgeon, to plan image-guided core needle biopsies of extremity long bone lesions that may be treatable with LSS. By using these guidelines, along with the aforementioned consultation, the radiologist will be able to preserve the patient's chances of receiving optimal surgical treatment.

We are pleased to inaugurate the Resident Resource Corner (your own RRC!) as a new feature of Current Surgery. We realize that there are many issues critical to success in your future practices that either are not covered during the formal residency training period or are addressed in an informal way. In addition, there is no mechanism for surgical residents as a group to let us know the kinds of information they would like to see in Current Surgery. Our goals with the Resident Resource Corner are to provide you with timely information about important issues in surgery, to serve as a forum for you to express your thoughts and ideas, and to highlight areas of interest we feel will be of help to you in both your training and the development of your future practice in surgery. Plans at present include addressing the explosion of information available on the Internet, providing help on exams and studying, and exploring business aspects of surgical practice. The corner will be monitored and mentored by three experienced surgeons: Joseph B. Cofer, MD, Susan E. Pories, MD, and Richard K. Spence, MD. Dr. Cofer is a general surgeon specializing in hepatobiliary surgery and the residency program director for the University of Tennessee School of Medicine campus in Chattanooga. Dr. Pories is a general and oncologic surgeon at the Beth Israel Deaconess Medical Center and actively involved in student and resident teaching. Dr. Spence is a general and vascular surgeon who serves as the surgery program director for the Birmingham Baptist Health Systems hospitals in Birmingham, Alabama. We welcome you to send any suggestions, comments, etc to us care of the journal, or you can e-mail us directly: Richard.Spence@bhsala.com or rkspence@ix.netcom.com, Coferjb@erlanger.org or jbcofer@worldnet.att.net, or Spories@bidmc.harvard.edu. We look forward to hearing from you. Dr. Cofer has provided us with the following information for this month’s Resident Resource Corner. ABSITE EXAMINATION ERRORS AND CONSEQUENCES

Introduction Society of Urologic Oncology (SUO)-accredited fellowship programs have undergone substantial expansion. This study developed a mathematical model to estimate future changes in urologic oncologic surgeon (UOS) manpower and analyzed the effect of those changes on per-UOS case volumes. Materials and methods SUO fellowship program directors were queried as to the number of positions available on an annual basis. Current US UOS manpower was estimated from the SUO membership list. Future manpower was estimated on an annual basis by linear senescence of existing manpower combined with linear growth of newly trained surgeons. Case-volume estimates for the 4 surgical disease sites (prostate, kidney/renal pelvis, bladder, and testes) were obtained from the literature. The future number of major cases was determined from current volumes based upon the US population growth rates and the historic average annual change in disease incidence. Two models were used to predict future per-UOS major case volumes. Model 1 assumed the current distribution of cases between nononcologic surgeons and UOS would continue. Model 2 assumed a progressive redistribution of cases over time such that in 2043 100% of major urologic cancer cases would be performed by UOSs. Results Over the 30-year period to “manpower steady-state” SUO-accredited UOSs practicing in the United States have the potential to increase from approximately 600 currently to 1,650 in 2043. During this interval, case volumes are predicted to change 0.97-, 2.4-, 1.1-, and 1.5-fold for prostatectomy, nephrectomy, cystectomy, and retroperitoneal lymph node dissection, respectively. The ratio of future to current total annual case volumes is predicted to be 0.47 and 0.9 for models 1 and 2, respectively. The number of annual US practicing graduates necessary to achieve a future to current case-volume ratio greater than 1 is 25 and 49 in models 1 and 2, respectively. Conclusions The current number of SUO fellowship trainees has the potential to decrease future per-UOS case volumes relative to current levels. Redistribution of existing case volume or a decrease in the annual number of trainees or both would be required to insure sufficient surgical volumes for skill maintenance and optimal patient outcomes.

The correct pathologic diagnosis of tumor type affecting the veterinary patient is of utmost importance to the veterinary surgical oncologist. The surgical oncologist may be presented with benign or malignant diseases, and an accurate pathologic diagnosis may be necessary to distinguish between the two conditions. In either case, assessment of surgical margins to determine completeness of surgical removal is necessary. In cases of malignancy, the pathologist should grade the tumor, if appropriate, and be able to perform specialized techniques, such as immunohistochemistry, if a diagnosis is in question. The surgical oncologist needs to understand the principles of tissue collection, fixation, and submission to help the pathologist provide an accurate diagnosis. Finally, the oncologic surgeon and surgical pathologist need to establish a cooperative working relationship and function as a team to discuss difficult cases. This will ensure the best treatment for the veterinary patient.

Purpose: Assessing the adequacy of the surgical resection during composite resection of carcinoma is limited by the ability to evaluate the bone margins. The standard pathologic evaluation of bone is by decalcification. Patients and Methods: A method of analysis was devised based on histologically proven methods of cortical invasion and subsequent spread. Frozen-section analysis of cancellous bone was investigated as a rapid method of evaluating adequacy of the mandibular resection. This report is an update of previously published results and includes an increase in the sample size as well as the analysis of additional pathology. Subjects consisted of 66 patients undergoing full thickness mandibular resection with 30 cases of histologically proven mandibular invasion qualifying for evaluation. Results on frozen section were then compared to the permanent section analysis on the cancellous bone and to the decalcified specimen. Results: Complete correlation was found between frozen and permanent section results. Frozen section analysis was able to correctly predict adequacy of resection in 60 of 61 margins. Conclusion: Based on these results, the oncologic surgeon can evaluate bone margins at the time of the resection and adjust the amount of excision required to eradicate the disease.

A better understanding of the physical and biologic principles of radiation oncology, along with improvements in the technical and clinical aspects of this field, have been gained in recent years. Some of these aspects are presented, with an emphasis on their relevance to the oncologic surgeon.Recent innovations have improved our ability to deliver high radiation doses safely and to increase the therapeutic ratio of radiation. They include the concurrent administration of radiation sensitizers and chemotherapy, altered fractionation schemes, and the conformal delivery of radiation using sophisticated imaging and planning tools.The increasing efficacy of radiation, resulting from innovations described in this review and others, enhances the role of radiotherapy in the struggle against cancer.

Advances in gene delivery systems have made possible the development of strategies to eradicate cancers via genetic manipulation. Although the strategy of ‘gene therapy’ remains in its infancy, experimental tumour models have produced encouraging results and have demonstrated that tumour growth or development can be altered by genetic manipulations. Investigators are hopeful that current and future human trials will confirm the role of these modalities in cancer treatment. This review focuses on several aspects of gene therapy that provide clinicians with a framework to understand the rationale and basic principles underlying current gene therapy protocols being conducted for cancer treatment. The relative merits of different gene delivery systems and the mechanisms underlying clinical gene therapy strategies are reviewed. In addition, we discuss the relevance of these new techniques to the oncologic surgeon.

5177 Background: PSC of the uterus (Ut) and ovary (Ov) are often treated similarly because of known similarities in their histology, biological aggressiveness and poor outcomes. In order to identify the need for more standardized treatment, the outcome of PSC of the Ut and Ov were compared in regard to their clinical presentation, treatment, stage at diagnosis, recurrence pattern and survival within the same institution. Methods: From 1991–2004, 327 consecutive patients (pts) were treated for Ut and Ov malignancy by a single oncologic surgeon. Of these, 46 pts were diagnosed as PSC (Ut =14 pts and Ov = 32 pts). The data were obtained from medical records, tumor registry, and follow-up reports. Comparisons were made in regard to age, stage at diagnosis, presentation, treatment, recurrence pattern and disease-free and overall survival. Results: See table. Conclusions: Ovarian PSC presents at a much more advanced stage, recurs more often and has much poorer disease-free and overall survival than uterine PSC....

Based on 25 years' personal observation of the history of head and neck oncologic surgery and the changes in multidisciplinary approach and teaching, a guide of preparation and self-evaluation for surgeons in this field is outlined.

The role of radiotherapy in malignant tumours of the orbit and the ocular adnexa is limited. In most cases there is a preference for surgical treatment.